3097 Good Catch: Fall reduction through an interdisciplinary approach in an academic medical center

Friday, January 22, 2010: 10:45 AM
Rozina Rajab Ali, RN, ARNP, MSN , Nursing, The University of Kansas Hospital, Kansas City, KS
Karen Wray, MSN, RN-BC , Nursing, The University of Kansas Hospital, Kansas City, KS
Jennifer J. Thibault, RN, BSN, MBA, CRRN, LNCC, SANE-A, CCM , Nursing Quality & Research, The University of Kansas Hospital, Kansas City, KS
Elizabeth F. Carlton, RN, MSN, CCRN , Nursing, The University of Kansas Hospital, Kansas City, KS
M. Suzanne Shaffer, RN, MN , Nursing, The University of Kansas Hospital, Kansas City, KS
Purpose:
Our high acuity academic center proved a challenging environment for engaging all providers in fall prevention. Despite multiple initiatives, patient falls continued. The goal of this project was to create ownership and an organizational culture in which everyone was engaged in fall prevention.

Significance:
Falls are the 6th leading cause of sentinel events. Over 20% of patients who fall in-hospital have a serious injury requiring additional intervention, increased length of stay, and over $20,000 in costs. The national patient safety goals and never events brought fall reduction to the forefront.

Strategy and Implementation:
A historically stagnant nursing falls team was transformed into a data driven interdisciplinary force for innovation. An investigation of best practices including a literature review and national conference attendance set the process in motion. A new corporate policy clearly stated expectations from all employees regarding fall prevention. Initiatives included new identifiers focusing on the universal caution color “yellow”, a high risk fall prevention bundle, and a post fall huddle to allow for real time evaluation of the event. A Fall Prevention campaign was launched with the tagline: “Great Teams Prevent Falls”. Fall prevention became a standing agenda item on Practice Councils and data was creatively disseminated via unit based monthly fall scorecards. Rather than being punitive, a positive reinforcement approach was utilized. From housekeeping to medical staff, engagement was supported via a reward system including the good catch initiative and celebration of falls prevention.

Evaluation:
Priority for implementation targeted the Acute Care Team, with specific goals to eliminate fall-related injuries and unassisted falls. NDNQI data for 1st Quarter 2009 showed 5 units with a 12-57% reduction in falls and declining trend lines. Four units have achieved a first-ever zero falls month.

Implications for Practice:
Successful strategies require organizational integration, access to data and ongoing evaluation of initiatives to support sustainability. Next steps will explore the use of technology, population based risk stratification and the utilization of pharmacist review to further fall prevention efforts.

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